Why physicians need to interpret your lab results

More than ever before, patients are receiving laboratory test results, with some of their numbers in bold or with “H”s or “L”s next to them. In some cases they’re getting them straight from the lab, in accordance with federal regulations. If not from the lab, they’re accessing their results on their physicians’ electronic patient portals. In some states, patients have always been able to request a copy of their results from the lab.

I support providing patients with their test results. It engages patients in their care, especially for conditions where it’s good to “know your numbers,” such as diabetes. Leaving patients wondering about test results, especially those ordered to evaluate symptoms that led the patient to see the doctor, can be anxiety-provoking, even if everything turns out to be “normal.”

Incorporating reporting of results in a practice’s workflow provides an additional layer of safety. If a patient expects a report and doesn’t get it, this may alert the physician to the fact that the results were never received by the office. The old “no news is good news” approach disregards the benefits of communicating test results and creates opportunities for errors.

Although increased direct access to results can be a good thing, we must not forget that there is a big difference between raw results and those interpreted by the person who ordered the test. For the non-clinicians who read this blog, I would like to spend the next few paragraphs explaining that difference.

Often, I get asked to “check some labs” by a patient or another physician requests results of “recent labs.” There are thousands of laboratory tests. Usually, we order specific labs to answer specific questions generated by a patient’s history, examination, or personal risk factors, or to monitor ongoing treatments. There are tests that we order in persons who are not having problems to find conditions where early detection matters, such as diabetes or high cholesterol, and even that short list varies by a person’s age, gender, and other factors. Talking about “ordering some labs” without the contexts that I just described is like going to a restaurant and asking for “something from the menu.”

There is an old phrase about “throwing spaghetti against the wall and seeing what sticks.” Some people believe incorrectly that this is how we utilize laboratory tests — order lots of them, see which ones are abnormal, and that will tell us what’s wrong with a patient. (Or, if they’re all normal, the patient is OK.) That is not how most of us use the laboratory. The true meaning of abnormal and even normal results depends on the question that led to the test being ordered in the first place.

Where do the “H”s and “L”s or the “normal” ranges next to the results come from? Typically, at least once a year, each lab obtains specimens from a group of healthy persons, runs many different tests, and for each test determines a “reference range” using statistical calculations. The reference range usually covers the middle 95 percent of healthy persons, meaning that 5 percent of healthy persons will have a result that is above or below the “normal” range. Each lab may have a different reference range for each test. So, having a high or a low value doesn’t automatically mean that there is a problem, or that there isn’t.

This also means that a healthy person has a 1 out of 20 chance of having an abnormal test (a false positive test), which should make everyone think before ordering. Often these false positives lead to further testing, some of it potentially harmful and expensive.

How do we decide when an abnormal test result is significant? By thinking about the question, we were trying to answer when we ordered the test and knowing a few things about the reliability of the test. Some tests are great at ruling out specific conditions if they’re normal but not in telling us which of several possible diseases is the cause of an abnormal result, or vice versa. That is why we order tests after deciding what we are looking for rather than indiscriminately ordering lots of tests, and why we need to interpret the results instead of just looking for the “H”s and “L”s. Keep in mind that sometimes a “normal” test can be a sign of a problem, depending on the situation.

Here’s a non-medical example of how the same “result” can be interpreted differently, depending on circumstances. You’re home alone late one night in a quiet house, and you hear creaking in the attic. You know that the sound could from be any of a number of things, ranging from the trivial to the serious, so you incorporate additional knowledge to decide how to respond. If it’s a windy day, or it’s a noise that you’ve heard many times and know to be insignificant, you may ignore it. On the other hand, if there have been break-ins in the neighborhood in which the burglars hid in the attic, you may end up calling the police.

A physician’s interpretation of test results relies on knowing what each result might mean and using what we know about the patient to draw a conclusion.

Increasing patient access to their test reports has many potential benefits. However, as stated in a 2011 ACP comment letter to CMS, we must not forget “the value that physicians and other health care professionals bring to the interpretation of laboratory test results in support of health care decisions in collaboration with patients.”

Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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Why physicians need to interpret your lab results 74 comments

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Patient Kit

One thing I can tell you from a patient’s POV about test results is this: Once a patient has received any bad test results in the past, waiting for any test results becomes a whole new ballgame. So, if you order labs for a patient who has, for example, a history of cancer and their current labs come back normal, if the doctor throws their normal results on the low-priority pile, your patient will still be worrying until you get back to them with their results. Also, we’ve all heard too much about lost test results to be comfortable with “no news is good news.”

EricMD

I think your right about the worry. So I think we should give incentives to doctors for spending the next 20 minutes talking to patients on the phone about their labs. We should pay them for their time just like an attorney or accountant.

Patient Kit

If a doctor spends 20 minutes on the phone with a patient, I have no objection to doctors getting paid for that. If there is a code for “encounter with burning water skis”, why isn’t there a code for “20-minute phone consultation about test results”? That said, if my test results are normal, I don’t need 20 minutes of my doc’s time. Why would you need 20 minutes to give normal test results?. A very quick but timely phone call just to let me know that all tests came back normal and there is nothing to worry about will do. That kind of call doesn’t even have to be from the doc himself. It can be from a staff member telling me that my doc wanted me to know that he has reviewed my test results and all is well. Like I said, once you’ve received bad results in the past waiting for any test results is stressful. So let us know ASAP please. If doctors can’t do that, then I’d like to be able to access my results myself ASAP.

vicnicholls

I save everyones’ time, the docs give them to me, I research, and then give questions. Less of their time because they don’t look at them unless I bring something up, they get my concerns & know I checked reliable data for it. We’re all happy.

Patient Kit

I was a professional research analyst before my life-changing layoff. Now I’m working a series of freelance, part-time and temp jobs, some interesting, some mindnumbing; none with any health insurance benefits or anywhere near the pay I made before (which wasn’t that much since I worked for a nonprofit organization)

But once a pro researcher, always a researcher. So I’m the kind of patient who does a lot of medical research too. I’ve actually watched 2-hour videos of real surgery similar to mine. It was fascinating. That said, I never bring or fax my docs research for them to read. I just go to my doctor appointments much more informed with a short, prioritized list of questions. I’m aware of the time constraints and always try to use the time we have together well. My research helps me ask informed questions and understand better what my doc is talking about. But I have never thought that I know more than — or anywhere near as much as — my docs about medicine just because I have good research skills.

vicnicholls

Here’s the caveat and I should have been more clear. I bring the research. If they want to see it, they will ask. They’ve asked at times, and seen notes I’ve made & the like, and know I’m ready to give a justification. The issue is they are secure I’m not doing “Dr. Phil” & they know why I have the questions & the context.

Saying someone knows more has to be taken into context. I’ve got a background in another medical field that tilts the “playing field” in my favor. People who have certain diagnoses can become quite equal in that specific area to doctors who don’t see those things every day. That is fair to a doc because I don’t expect them to know everything with all the ins/out for each patient. If you are a family doc, I wouldn’t expect you to have as much in depth knowledge of say, nutrition, I have. That’s where the patient needs to spend time helping their doc out by working to educate themselves with medical information. Doing what they can to bring attention to issues for their doctors.

That doctor takes the information and then relates it to other things, using their broader base to direct. That’s the point of a relationship: working together, strengths and weaknesses, to build each other up.

Cheryl Prevor Psy.D

I’m completely sympathetic to the amount of time a physician spends trying to satisfy their employer or just making a living. A good question to ask your patients is if they are personal friends or have relatives that are physicians. I know that might sound strange but it will help doctors gauge if the patient has an understanding, and thus empathy and respect for a doctor’s time.

I can say that the majority of patients tend to presume that getting the results of tests is part of the fee they or insurance pays for the initial appointment and the actual tests. I’ve recommended to a few practitioners to place in their initial patient agreement if they will charge for “phone calls” and if so how many minutes & costs. Most psychotherapists and psychiatrists have this as do attorneys. It’s a fine line and one that needs further evaluation.

Luxurychick

Why is it that the question has to be labeled stupid? I’ve had people ask me questions pertaining to my line of work and I never thought it was stupid. It’seems this time of stuff that has caused the public to lose respect for the profession or they may skip the doctor altogether, gather the info and ask someone that knows how to decipher the information free of charge.

FEDUP MD

Do you work for free? Just asking. Again, not talking about an offhand generic question at a cocktail party that takes you 30 seconds to answer. I mean, do you work for an hour plus a day or more for no pay answering very specific questions? What if this amount of time just keeps expanding and adding on to your workday? Do you expect to call up your lawyer and ask his or her advice for 20 minutes and never receive a bill? Do you get a plumber out to your house to ask questions about your pipes for free, even if they don’t fix it? Or do you value their time and expertise enough to reimburse them for the information they gave you? Why are physicians suddenly evil when they want the same thing? Especially because as a physician you are still on the hook malpractice liability wise for anything you told them on the phone, but got no income whatsoever. As soon as I get paid for phone consults, I will be more than happy to carve out time during my workday to do this. Otherwise, I am not losing money by scheduling fewer paying patients, or not ever seeing my kids before bedtime to talk on the phone for free all night.

Luxurychick

Actually I do answer a lot of questions in regards to the business world for free. Furthermore, my comment didn’t say anything about that. I specifically stated that there was no need to say that any questions are stupid. Furthermore , we each chose our profession and have to live with it. My college mates call for free advice just like I call them for free advice.

doc99

You can’t get more than what you pay for – First Law of Thermodynamics

Patient Kit

That must mean that the vast majority of Americans can’t afford medical care.

FEDUP MD

I am not asking if you provide general advice to friends for free. I am asking if you offer your work to your clients for free. I actually don’t think any questions are dumb. I do think I have years of specialized knowledge which I spent a great deal of my own time and money obtaining, and I am not obligated to give my professional time away for free. If you want or need my professional services in depth (i.e. More than my nurse telling you results are normal) than you can pay for it.

vicnicholls

Um if you are salaried, you work for free at some point LOL … that’s why they give you a salary ROFL

FEDUP MD

This is why I have staff call with normal results, and if abnormal in any significant way (rare) bring them I for appointment, often same day or the next. If they want to go on about normal results for 20 minutes they can make an appointment. For all of you who are incensed that I want to get paid for work I do, which pays the salaries and benefits of many people who work for me, as well as provides for my children and their future, I suggest you spend a significant amount of your day working for free too.

Ladyimacbeth

Speaking of wanting results ASAP….This reminded me of a patient who somehow got the pager number of the physician I work with and paged him during a very busy clinic day to find out her UA results (which were of course WNL). I don’t think I’ve ever seen him look so unhappy.

Patient Kit

Just to clarify, when I say ASAP, I don’t mean the moment the test results are received. I mean within a reasonable time, say a few days. My docs all do get back to me with test results within a reasonable time, sometimes even the next day. But I do understand that I am not their only patient and, in the case of my GYN oncologist, all of his patients have cancer and many of them are much much sicker than me.

Patient Kit

At least $500/hr, huh? Maybe you should have been a lawyer. Have you considered going back to law school? Maybe you’d be happier as a lawyer. But be forewarned — a lot of people really hate lawyers. Define “working for free”. Does someone who works for an annual salary work for free when they stay 5 extra hours in a day to meet a sudden tight deadline? What if their workload doubles after a wave of layoffs but their salary stays the same? Are they then working for free half the time because they’re now doing the work of two (or three people)? Do doctors who are paid by annual salary consider phone calls to patients working for free or is it just part of their jobs? Maybe those who say fee-for-service is the problem are right. I’ll have to rethink about that. Sometimes it sounds like doctors who are paid via fee-for-service resent that there is no billing code for smiling at a patient.

EricMD

They hate doctor too. The difference is lawyers get to sue insurance companies and get away with it.

And doctors shouldn’t work for an annual salary and if they do then they have no reason not to talk to the patient except that the salary they get is still based on the number of office visits.

Patient Kit

Wow. If you want to charge at least $500/hr as a primary care doctor, maybe you should consider converting to a concierge model, treating only wealthy patients. You’d have a lot of competition for that tiny slice of patients so you better be an exceptional doctor with a good personality. Most patients simply can’t afford your $500/hr minimum. Alternatively, since you can’t stop thinking about how much money lawyers make, maybe a career change to law. You could defend doctors in malpractice cases. Or, if you really want to go over to the dark side and money is the most important thing to you — you could sue doctors.

Jewel Markess

The cost of living in NYC is a lot higher than everywhere else. I’d imagine top medical specialists in best clinics in NYC are paid pretty well too. Incidentally, the lawyers that are paid 1000/hr are probably just a few famous names. I dated a lawyer once – he didn’t make that much, probably less than what I made as a software engineer. I just googled and according to the Bureau of Statistics, the average salary for a lawyer is 130K a year – a nice chunk of money, but not huge considering that there are a few who are earning 1000/hr.

FEDUP MD

All of those situations as you describe, indeed, are working for free. Just because America has become a horrible place for everyone to work doesn’t mean that we should just let it continue to happen to more people. In fact, when one of those situations happened (laying people off and making the remainder wor, more) at my husband’s company. You know what happened? The remaining workers flew off like rats off a sinking ship to other companies, and gave the reason that they weren’t going to work for free, baffling and eventually shuttering that company.

Patient Kit

I basically agree with you. But doctors should have paid attention to and cared about what was happening to most of the American workforce a long time ago. But you, for the most part, didn’t. And now most potential patients, who can’t afford lawyers, can’t afford to pay doctors $500-1,000/hr (like lawyers) either. I see a lot of outrage expressed here by doctors about people who get paid more than doctors. But I haven’t seen much outrage about what many of your patients get paid. It’s all connected. I value what doctors do very much. But I will never have the money to pay you the fees you’re talking about. Most of us won’t. Hence, we will need a tax-funded third party healthcare system in order for all Americans to access medical care. The market for direct pay doctors charging $500-1,000/hr, I regret to tell you, is extremely tiny and elite. There are not enough of those kinds of patients to go around.

Patient Kit

So, if you want to be paid at least $500/hr, if you converted your practice to direct pay, you’d charge your patients at least $170 for each 20-minute visit? And also bill them for any time you spend on the phone with them or reviewing test results, etc? Good luck finding enough patients. Do you have any idea how many people cannot afford lawyers? II had to be my own lawyer in court a couple of years ago going up against a real lawyer. It was not fun. But we worked things out in a way that was fair to both sides.

Jewel Markess

I actually have a different scenario when it makes sense not to call your patient ASAP. Let’s say it’s Friday 4pm (or earlier and you have someone’s home number), you call someone and get an answering machine. Don’t leave a message “we got your test results, please call us back to discuss” when you know full well that the person will likely not be able to call you back the same day and will spend the whole weekend worrying – maybe for nothing. My friend who had a history of cancer got a similar call. The funny thing is that her results were normal, but because she got this phone call, she spent the whole weekend going crazy. Now, given that she wasn’t at home, and it was close to the end of the work day on Friday, it was a reasonable assumption to make that she’d not be able to call back the same day, but this ominous-sounding message ruined her weekend and likely caused her blood pressure to spike.

The same issue of late Friday (or at any time on Friday when you are calling someone’s home and the person works for living) is a problem for healthy people after routine visits too. I had a doctor tell me “if the test is OK we’ll send a letter, if something is abnormal, we’ll call”. OK. I got the call on Friday evening when the office was closed, but since there was no information in a call and the fact of a call implied that something was wrong I spent the weekend worrying. When I called on Monday it turned out the doctor left for a vacation, but after I explained the situation, the nursed looked it up and it turned out that my cholesterol was elevated. This couldn’t have been described in a letter? For the record, my 10-year heart attack risk was less than 1%, so was something like this really couldn’t have been put in a letter or wait until the doctor is back?

joehospitalist

Wasn’t it a part of meaninful use that doctors office’s have online labs patients can check? I feel like that’s challenging for small doctors offices. Now they had to pay for another service, and provide tech support, deal with passwords, etc etc. For a country that says how badly we need primary care doctors, we sure don’t make the environment easy for them to practice in.

Patient Kit

So, leave medicine then. You clearly hate it. And patients are better off without a doctor who hates being a doctor as much as you seem to hate being a doctor. If money is your highest priority, go work for Pharma, an insurance co or the administrative side of a hospital system. Do you think you might be happy doing that?

EricMD

I don’t know. But I’m working on it.

Patient Kit

I sincerely do hope you find something that makes you happy.

Peggy Zuckerman

I support fully the patient having the same immediate access to the labs that the doctor has. I also support some basic education–which can be part of the report and/or available on the internet, linked through the doctor’s website–which teaches some number of patients about the issues which seem “stupid” to some. But many years of being denied our labs, not being able to study them in advance of the next appointment, finding out later that a significant lab result was never seen by the doctor, ie, the one which should NOT read normal in light of the patient’s conditions, and the list goes on. Give some respect to the patient in this regard and help him understand what is a reliable source of information.

Don’t want to talk to your patients about the tools that you use, or answer questions after blocking is access to that data, and failing to understand his anxiety about his health is a perfect way to create the mistrust of the health systems and its providers, non-compliance with recommendations, the reliance on quacks, and the general threat to change the entire system to one which will be Washington, DC-centered vs patient-centered.

vicnicholls

and one which SIDM will continue to keep hidden.

I use AACC’s labtestsonline and it is the cat’s meow. I even asked about an esoteric ‘lab techs haven’t seen’ test and they gave me the titles of books of who wrote the stuff for the test. AACC is hands down excellent.

Peggy Zuckerman

I understand that your time is valuable, as is mine, which is why I want to review my lab results before going in to see the doctor. If I receive a call /request to see the doctor re the results, I especially need to see them so that I can try to understand them, get my questions in order, and be a responsible patient.

If the problem seen by the doctor requires additional tests, and with that additional consultation with the patient, that is obviously the type of work that requires payment. There are just too many instances in which lab and/or imaging reports hold information which may be overlooked by the doctor, or mistakenly filed without review in the patient’s file. Having the second look by the patient should be seen as a help, not a burden to the medical system.

doc007

The payment you receive for the office visit when the blood was drawn is supposed to cover the cost of reviewing the results with the patient. If you are fee-for-service, then it is certainly ‘fair’ to bring a patient back to review more complicated results, but remember this is not always convenient for the patient. That patient has to take time off of work to come in (possibly costing them dearly), must fight traffic (possibly risking their lives) and buy fuel to get to your office. So it comes down to how you feel towards your patients. I’ve practiced for over twenty years now and always call my patients with results. I admit that there are times when I want to bang the phone on the desk (and have), but I remind myself that they lack the knowledge and are depending on me to make them feel better. Isn’t that why we became doctors? I’m quite comfortable with my income but, yes, it can be upsetting to know that there are those in other industries who get paid far more for doing things that don’t come close to the value of saving lives. I bet your patients would rather be stranded on an island with you than their lawyer so remember what you mean to them. There will be a day when patients no longer need a physician to interpret their results and you’ll be missing those annoying phone calls. In the meantime, remember how much they value you. Sometimes that’s worth more than a few extra bucks. If not, it may be time to move on. PS. An elevated hematocrit shouldn’t be blown off…

Patient Kit

Thank you. None of my doctors, who I like, respect and appreciate very much have ever made me come in for a follow up office visit just to get normal test results so that the doctor could bill for giving those results. Obviously, abnormal/bad/complex results that need discussion and a treatment plan are a whole other thing that does require a follow up visit.

We live in a world in which nurses, teachers, firefighters, police all make much less money than corrupt hedge fund managers, Alex Rodriguez and Kim Kardasian. Whatever that says about what we value as a culture, I can tell you that I do not value A-Rod more than my awesome doctors. It’s a mistake to get obsessed with the fact that some people make more money than doctors doing something far less important. That is unfair but is not going to change anytime soon. I understand that there are a lot of pressures to deal with in our dysfunctional healthcare system. But I also have a hard time believing that most people who were drawn to become doctors would have been happy working on Wall St or as lawyers.

BTW, I like your name, doc007.

Faxon

Thank you. You sound amazing, like my internist. I am so lucky to have him as a doctor!

vicnicholls

doc007 for the record some of us bring goodies to the office (learned that from my predecessor) and we send cards and the like for doctors day! Some of us write and bug the admin so that good people don’t get the shaft.

Cheryl Prevor Psy.D

I agree with your post in terms of the importance of all involved understanding why certain lab tests are ordered and of course agree that it’s near ridiculous to just order tests blindly but I do perceive there to be flaws in the overall message.

My background is as a clinical psychologist but I’ve been a medical patient for over two decades. My focus as a clinical has nothing to do with psychotherapy anymore and all to do with the cognitive and emotional processes that go into medical decisions (both patient and healthcare providers).

The challenge of what you’ve expressed is the assumption that a physician has listened carefully and accurately and orders the correct tests to assess a patient. That is a unique skill that is often flawed and frankly over confident. All of us are vulnerable to issues of bias and as you know many studies indicate that within I believe it’s two minutes a physician has made up their mind as to what may be wrong with the patient. In doing so many inevitably miss ordering the critical tests this decreasing the reliability and validity of the actual tests ordered. Patients, especially those with more complex or chronic illnesses know this and the discord that arises when physicians won’t order the extra tests damages the relationship. I’ve found in my work this is especially true for tests that are benign in nature: labs or scans.

Alternatively it sounds like you’ve made an assumption that these labs are read correctly, all of the time, by the physician, PA or nurse relaying the results. For myself and the clients I’ve worked with, errors in reading the labs and reporting them is extremely high. I’ve seen overt disregard for those “H” & “L’s” but more problematic ally I’ve seen a disregard at looking at any tests that don’t have those alert markers. You stated the statistics of the lab ranges so in doing so we cannot forget that it is not only critical to diagnose but catch early. Patients whose testings are falling into patterns are just as critical to notice and report. If patients are to exclusively rely on health professionals to look at their results I think due to time issues alone physicians will miss most of the warning patterns that are developing. You can really see this in blood cancers and endocrine disorders. Again, patients know this and it’s scary for them. It’s scary if they fear they have say Leukemia for whatever reason and no one is noticing and ongoing drop in platelets. In my work, noticing the patterns is critical to early diagnostics. Patients who are actively involved in their care read their results to help you help them. They aren’t trying to be difficult and resent the often developed perception. When you have a patient who is actively wanting to see their records/labs/reports, it usually means you’ve missed something and I think we as practitioners can accept that without judgement or damage to our ego the process of helping a patient is greatly improved.

While doctors are as human and fallible as anyone else, all complex societies rely on the expertise of specialists. We do not and cannot live as generalists, hunting our own food, making our own homes, building our own technology. I trust the bridge won’t collapse, the wheels won’t fly off my car, the bank will return my money when I ask for it. And so it is with doctors. There are checks and balances: state licensure, lawsuits, the power of the marketplace. But ultimately patients, and we’re all patients eventually, rely on doctors just as we rely on road engineers, car mechanics, and banks.

The cognitive biases you mention are certainly cause for concern, particularly as they affect everyone, not just doctors. It is at least as likely for patients to distort isolated findings, miss “warning patterns,” or ignore the risks of false-positive test results as for doctors to do so. The best way to monitor and improve the expertise of specialists in any field is peer review, professional standards and guidelines, ongoing professional education, and often licensure and governmental oversight. In contrast, a stance that counsels the untrained to disbelieve and double check everything themselves is a recipe for paranoia, not healthy living. Do you check every bridge before you cross it?

When you have a patient who is actively wanting to see their records/labs/reports, it usually means you’ve missed something

No, it usually means they don’t trust me, or they think I missed something, or they have a strong need to be in control, or some combination of these. Which is fine, everyone’s entitled to their opinion. But much more often I catch my own mistakes, or a colleague does, because we’re in a far better position to do so.

Cheryl Prevor Psy.D

I agree with almost everything you say. We are all vulnerable to bias and failure. In fact, one of the largest problems is that patients are often horrible at their own narratives. They tend to present in a disorganized manner that is difficult to follow in the short windows of time scheduled for the appointment and/or they present a “bankers box” of records and naively presume others can or will sort through them. My clients don’t do that because I assist with organizing and literally will do a role play with them so the actual exchange with the doctor is prenavigated.

But your opinion on the other concerns me.

You quoted me and then added your comment. You are under the sad and biased opinion that if a patient requests their labs/records that THEY do not trust you, when in reality the almost guaranteed likelihood is that someone prior to you has failed them in some way & requiring their information is a way for them to attempt to prevent that from happening again. You’ve made it about you, which with all do respect is ego driven. It’s not remotely about you, it’s about their history and that warrants empathy and reassurance. If they think you’ve made a mistake and that borne a you, I’d suggest talking with the patient and getting a better understanding of their concerns.

Statistically, and I know this from analyzing hundreds of medical cases, physicians will make at least one error but usually more with every single patient. And that’s ok. Usually those errors are quite minimal, sometimes quite significant, but to deny that any error could be made and that a patient should blindly trust a physician is rather silly. Doctors aren’t bridges. They are human beings whose subjective opinion is formed by rather interpretative study. Additionally and this is the key part I want you to hear… As a physician you may be perfect but you are relying on numerous others aspects: such as lab technicians, machines, radiologist, patients following instructions, dosing, samples stored correctly etc. it’s unkind and unfair to expect any person to fully trust in all those aspects and individuals. Most of the errors doctors make originate from two things:
1) not listening & self biases
2) errors stemming from testing not considered.

Although I am a practitioner, I am also a patient. I grew fascinated with this subject when 8 major physicians read a pituitary/brain scan wrong & I ended up finding what they missed. This was compounded by 3 major institutions misreading critical pathology. I did correct that too by sending my sample out of area. Not one of those practitioners would ever want to hurt me or misread anything. It had to do with the initial evaluation on both creating a bias when others viewed. The mind is amazing like that. They saw what someone else said they saw and in doing so actually threw out logic as the pathology especially warranted correlating blood values. When I personally go to a new physician of course I check everything. They are not a car or a bridge they are human just like me. If you can tolerate a patient needing to get their records to be reassured that you will do a better job than someone before you, the trust will naturally form as it would for any relationship.

Doctor-patient relationships are a lot like dating. It takes time to feel comfortable with a new person. Just because someone has MD after their name doesn’t remotely mean that they will do a better job than someone before or even the patient. The patient is 100% focused on what’s happening in their body, the physician is focused on 100’s of patients and thousands of disorders. If you listen more and are less defensive, I can promise you that you will not only be seen as a great asset but you will decrease your threats of malpractice and increase your online opinions.

It’s not about the doctor. It’s about a patient knowing that you only have 5-10 minutes in your day to consider their health.

Cheryl Prevor Psy.D

pS: bridges and cars are repeated tested to insure they are functioning as intended and in a safe manner, it’s a beautiful thing we as people don’t require that but I know you equally would agree that you often wished people were periodically checked

In your fervor to correct me, you make a couple of logical errors. I wasn’t comparing doctors to cars or bridges. I was saying that the work of a doctor is similar to that of other experts. We are all fallible, and yet society as we know it could not exist without an assumption of trust. Doctors betrayed your trust by a missing an important diagnosis. This unfortunately happens far too often, but thankfully much less often than doctors getting it right. I listed the best ways to prevent such errors in my comment, and hypervigilant patients isn’t one of them. Yes, there are plenty of online anecdotes about patients diagnosing themselves when their doctors failed. This is bound to happen on occasion, bright buoys in a sea of doctors getting it right.

I’m not arguing for blind trust, only for perspective. I wonder how you’d feel as a clinical psychologist if the same suspicion and mistrust were applied to you and your work.

Another logical error: “You are under the sad and biased opinion that if a patient requests their labs/records that THEY do not trust you, when in reality the almost guaranteed likelihood is that someone prior to you has failed them…”

I stand by what I said — and by what you inadvertently repeated: they do not trust me. This can be due to past betrayals or for some other reason. It certainly doesn’t mean I’m missing something. Indeed, it isn’t about me at all.

I agree: trust in all human relationships must be earned and takes time. I hope you’ll agree that mistrust should be earned too. I don’t insist that anyone trust me personally, nor psychiatrists as a group, nor physicians or mental health professionals more generally. Nor (for example) men, or Americans, or some other huge group I belong to. All I ask is that we meet with an assumption of good intentions on both sides, and see where it goes from there.

Cheryl Prevor Psy.D

Hmm. I actually didn’t perceive my response to you as a means to correct you, rather as a dialogue intended to enlighten as we are, as you said, failable.

You said it best:
“society as we know it could not exist without an assumption of trust.” But you have made the assumption of distrust by assuming that if a patient wants their labs that they either have control issues or that they don’t trust you. That’s not trust, that’s bias.

Here is the deal, you made a metaphor that when you drive across a bridge you don’t question the safety so to speak. Perhaps that’s because things like bridges which are of course built by experts are repeatedly monitored for safety and if all parts are effectively working as they should. Millions of cars drive across and if a bridge did have an issue and no longer operate on the level of skill expected, within about 5 seconds we’d all know about it on social media and they’d immediately without hesitation or review – shut the bridge down until they authorities were certain. We do not need nor should we have casual trust in any human being because they have a degree and job. Millions of people have degrees and jobs.

It doesn’t remotely bother me if a patient didn’t trust me. When I worked in psychotherapy I’d actually expect the patient not to trust me until I earn trust. But a therapists process involves hours and hours of sitting with a patient. It’s entirely different.

I don’t know why it seems to bother you if a patient doesn’t trust you or a colleague.most patients would absolutely rather have access to order labs or scans but they can’t so they must go to a physician. There is no reason for a patient to trust anyone with their lives unless they have come to work with the person and trust is earned. If that upsets you, that makes me sad and it’s unfortunate but I’m guessing that you e (fortunately) never been a patient with anything serious. If you choose to rely and trust yourself that’s great but don’t blindly trust all of your colleagues that are helping you by running the tests.

Someone was last in their class in medical school. Would you truly trust that person with your life or that of a spouse or loved one?

No. It’s a natural process that all of us with degrees and jobs need to face. We are no longer “better” because of these things but hopefully we can greatly contribute to improving another person’s life

You began with: “When you have a patient who is actively wanting to see their records/labs/reports, it usually means you’ve missed something…” This isn’t even remotely true, and it telegraphs your bias against physicians. You later conceded that such requests “aren’t about you” (the current doctor), that to assume so is “ego driven”, and that it’s mostly triggered by experiences with PRIOR doctors. Physicians are at fault one way or the other, the only task left is deciding which ones to target.

Patients actively want to see their records for a variety of reasons. On occasion they’ve researched their esoteric problem more than the doctor has. Sometimes they need the records for a legal matter or disability claim. But in my experience it is more often a trust or control issue. I apologize for the political incorrectness of my saying so, and indeed, the mistrust or need for control is often completely understandable and even justified. Patients may have been hurt by past medical misdeeds, as you said was true of you, or they may transiently feel a need for control in the face of out-of-control disease. They may have obsessive characters and simply prefer to have all the facts at hand — many doctors are like this, for example. Alternatively, they may be suspicious of doctors, all authority figures, or of people in general. We got on shaky ground with your initial speculation about what wanting records means.

My comparison to bridges extends to nearly all facets of modern life. I won’t bother to list all the examples that are not “repeatedly monitored for safety” or that wouldn’t become instant news on social media. You seek assurance that doesn’t exist in real life. I don’t check my doctor’s class ranking, just as you presumably don’t check whether your kids’ schoolteachers had felony convictions in other states, or whether your tax preparer’s vision is failing.

In a couple of comments you’ve written that patients can interpret their own lab results and that they “would absolutely rather have access to order labs or scans but they can’t so they must go to a physician.” I gather you don’t find the original poster’s arguments persuasive that expertise helps in ordering and interpreting labs. We must agree to disagree here, as I’m off to give all my friends Rorschachs and MMPIs that we’ll interpret ourselves. After all, why use a psychologist when there’s so much we can learn online?

Cheryl Prevor Psy.D

It seems to genuinely bother you, the idea that patients might perceive you’ve missed something. Because when it comes down to it I am suggesting that, be it prompted by you personally given that you would even devalue a patient by suggesting they looked up their “esoteric problem” or simply because a lot of things do get missed and it’s unlikel that if you treat adults that you are the first doctor they have seen.

It shouldn’t bother you that patients want their records or that they believe that they could possibly see something you didn’t. Seems near impossible for a physician these days to pay 100% to every patient they see and as I’ve expressed numerous times I have empathy for that struggle.

In psychology, people repeatedly do believe they can solve their problems and in fact do every day. Patients would prefer to solve their own medical problems. The difference is they can process their experiences, but they can’t order their blood tests.

I actually don’t work as a psychotherapist. I’m a high end medical consultant who assists with navigation and insuring accurate diagnoses and minimizing additional treatments. I’ve worked quite a bit at correcting cancer and related tumor disorders so all that you are saying about the MD’s expertise being more significant or valuable than a non MD doesn’t make sense to me. In fact, sometimes, less sensitive doctors actually bring me in because I often do see things they missed. We’ve come a team. And sometimes I work for the patient, and we become the team.

You might be a fine physician but it’s come out that you don’t truly respect patients.that makes me sad because without that you will lead with your biases and you will miss likely some important things.

It seems to genuinely bother you that physicians might have some expertise that you lack. But no worry, we know instead that you’re a “high end” medical consultant — and a former model to boot.

Somehow it’s devaluing of me to imply that esoteric problems like yours are more likely the ones where sufferers have learned more than their MDs. This is not only common sense, your objection devalues physicians. And you continue to devalue us with virtually every comment. “All that you are saying about the MD’s expertise being more significant or valuable than a non MD doesn’t make sense to me.” Amazing. Is a psychologist’s expertise more significant or valuable than a non-psychologist’s? Why do you sign yourself PsyD?

I’d welcome removal from the gatekeeper role, and people ordering labs, scans, and all their meds without involving me. If not for the inevitable carnage, that is. Then I could serve solely as a consultant to those who truly want my services, and not have to deal with people like yourself who do not.

I respect patients, it’s hypocrites like you I don’t respect. Talk about leading with your biases. I’m done with this thread.

Cheryl Prevor Psy.D

You are a very strange man Doc and extremely defensive of a physician. In that sense you interest me. You decide to sign off on a thread in which you asked me questions but aren’t actually seeking answers, thus there is an odd arrogance going on where you want to have a discussion but only on your terms. That said, I’m not done with the thread so read is you wish or don’t.

Suggesting patients have some esoteric problem and connecting it with saying that the patient found it and the MD didn’t is devaluing. It suggests that a patient could only find some weird out of the ordinary issue because they focused on it. Patients deserve more credit than that. But your words indicate you do not feel this is true.

This topic post explored the importance of having a professional read results. I believe this to be completely true but I don’t think it remotely suggests a lack of importance of a patient reading reading their results. You seem to think it does. Let’s be honest here, the amount of time it took in med school to understand how to read a lab result was not long. Most patients are certainly capable of doing such a task . And because it helps them feel more informed, because it assists the process by adding an additional set of eyes, any doctor who feels a patient incapable of adding such value is kind of a fool. They don’t have the time and it is statistically more likely that a patient reviewing their own records will indeed be able to catch a trend in change of values with as much if not greater ease than a physician would. It’s just a matter of math & the time physicians spend per patient vs the amount of time a patient trying to get well would invest. And I’ve seen patients catch amazing things. I’ve seen physicians catch amazing things too. Good healthcare is a team effort.

When patients come to see a psychotherapist, it’s fair to presume they are dealing with something that makes them feel they need professional assistance. But our goals as psychotherapists are that the patient will no longer need us, that they will through our work together develop a set of tools that allow them to function without a professional. Medicine is completely different. If a patient could fix themselves they would (like therapy) but in medicine a patient is not legally allowed to order tests or medication. That’s what I meant when I suggested if they could they would. I of course believe physicians want their patients to get properly diagnosed, treated and well, but but I just find you through our exchanges to be holding onto some antiquated mentality where the doctor is somehow better than the patient that they and they alone have the capacity to know best. Not really. A lot of patients I know simply chose to go into other professions but they are quite book smart and had they chosen med school is suspected they would have excelled. Let it go… Let go of that antiquated thought process and you will absolutely become a better physician than you are. Your relationships with patients will be richer and more satisfying and you’ll end up becoming as respected as you seem to want to be.

And now your questions. I call myself a “high end” consultant because I often work on very complex cases involving those that if not identified correctly and with thought put into alternative testing would lead to death. I think understanding nuances of genetic markers in cancer and the complexities of how certain treatments may impact specific individuals is fairly classified as “high end.” I love what I do. I love the investigative challenge. I’ve even had the opportunity to be involved with the FDA and other branches of government that handle cases. But I’m extremely private in my work and I hope that my efforts will continue taking me to exciting new opportunities.

I keep the Psy.D because I achieve my work & sort through medical data through a process that requires extensive knowledge of the psychopathology of participants in medicine, that’s understanding how personality types (patient and healthcare professionals & organizations) navigate & form & enforce medical decisions. This naturally includes a specific focus on cognitive errors and the core personality reasons behind them. So I think it’s fair to say I probably do notice many things that others don’t but that I’m also vulnerable to being wrong. To offset that risk, I do have and take a luxury of time that MD’s simply cannot. I suspect that is why you are ultimately not fond of me & resort to silly comments like pointing out that I was a former model (yep. Good for me personally, bad for diagnostic purposes). Im not even sure if you recognize how childish that was given that to get that information you’d have to read other posts I made with different people as we never chatted about that. I didn’t once look at what else you wrote. You are unable to see the silliness in your exchanges because you think on some level I’m judging you so you are trying to judge me. I’m not judging you. I’m just seeing you and listening and that leads me to think about how you might interact with your patients & I do suspect you’ve had several moments where patients didn’t appreciate how you made them feel. And it’s ok. I know I’ve had interactions where doctors didn’t like how I made them feel…. But in these moments I was the patient there for medical help for real medical situations. That was not the time for a MD to express personal feelings. Although I hope you do I don’t suspect you see the difference.

I don’t think I devalue doctors in general but there are certainly some I don’t think should be allowed to practice. There are also MD’s I know that are brilliant scientists but morally corrupt human beings. And there are others I adore as people and as physicians and I’m very grateful for their presence and assistance in my life. I see things more broadly, with all sorts of colors so to speak, you see patients who want their records as having control issues and really not that much more.

There is so much more to it.

Be well.

vicnicholls

Now you know one of the reasons why the SIDM list doesn’t like me. I was debunked due to my appearance, background, and asking questions that hit bullseyes. I’m sorry you are also on the receiving end of ‘doctor knows best’.

vicnicholls

You must not be busy. All my docs are. This is why I try to have every duck in a row and be prepared for their visits. I rattle off all the specialists, test results not WNL, etc. to busy generalists and specialists. They don’t have time to spend 10 min reading things & flipping thru 5 pages of notes & results. I give them the highlights and answer questions.

Its called understanding something of a docs’ professional life and trying to help.

I applaud your conscientiousness. Because I mostly see patients in psychotherapy, I am paid by them (by the hour) to go over their labs, or whatever else is on their minds. I even spend 20 minutes or more on med-only visits, and can review labs without hurry. Other doctors are in a very different position. Nothing wrong, and much to gain, by bringing pertinent matters to their attention.

vicnicholls

Thank you ma’am. Couldn’t have said it better. I wouldn’t say missing something, I’m the one the docs depend on to keep everyone in the know. I help them out. They help me, we are a team. I don’t care who misses what but we work together to fix it.

That’s the real deal.

medicontheedge

So you can get a second opinion from Dr. Google?

vicnicholls

I don’t have Dr. Google but I have Dr. AACC Labtestsonline, Dr. PubMed, Dr. UpToDate, Dr. Clinical Key … all of whom medical professionals trust. I look at Blood, Gut, etc. Those are how I form the opinions. The better educated & savvy the patient is, the better they can take advantage of docs’ learning.

fos

The story seems fine until you find cases where the lab results are not well explained/interpreted by the medical doctor. I had to analytically compare my own lab results with those of the patient to refute the conclusions made. It is worth mentioning that this situation did not happen in the States; otherwise this would be a potential litigation.

Faxon

“And no there is no code that pays for a phone consult. There is a code for a phone consult.” Which is it? Yes, you should be paid for communicating on the phone or by email with your patients. Because for me to come into the office, missing several hours from work, to find out something that could have been communicated with a 5 minute phone call is unacceptable for the patient.

T H

The two are not mutually exclusive. Just because there is a code doesn’t mean it is reimbursed.

Because ensuring that there is no misunderstandings by dealing with labs in a face-to-face encounter (inicidentally, which IS reimbursed) can be worth its weight in gold for both the doctor AND the patient.

vicnicholls

Would you like to talk to my docs? The teaching doc specifically? I guarentee you they’ll say welcome to the new world, because we learn from the same places you all do (and check out medical library books too). There are many savvy patients like me that we work in tandom and learn things. You don’t need an MD to do basic things.

vicnicholls

That’s another reason I like my own stuff: my docs can give that time to other issues.

“Empowerment” is a tricky thing. As a mostly-psychotherapy psychiatrist, I tell patients that I hope to make myself obsolete in their lives. I go over labs with them line-by-line (fortunately, I don’t do a lot of labs). The whole message and aim is empowerment. And for a good example of an empowered patient right here, I refer you to Patient Kit, who conveys a great deal of empowerment without being adversarial. It’s an adversarial stance in the guise of empowerment that I object to, and that’s what I read in Dr. Prevor’s comment.

Cheryl Prevor Psy.D

I like that. I’m going to take a look at that. Patients just trying to get well aren’t trying to be adversarial, in fact they are terrified that a doctor will perceive them as such.

They just want to figure out what is wrong with them so they can go back to living their lives.

vicnicholls

Dr. Prevor, there are a good number who have had negative experiences with doctors. Some have to stand their ground. For those who have things like fibromyalgia, doctors’ don’t take them seriously and if you are sick and hurting, get blown off, well tell me how your female partner/spouse/girlfriend would react when that happens?

Just like a patient. Too many times we do have to stand our ground. One of my favorites is when a GI (out of residency for a year) told me that my albumin would be low if I was malnourished. I said no, check out the Minnesota Starvation Experiment (and the latest in nutrition research). Looked at me like I had 3 heads.

If you check the research, I’m right. So why should we trust when things like that happen?

Cheryl Prevor Psy.D

LOL. You are singing to the choir so to speak. I’m so sorry you’ve obviously had to stand your ground but I fully support and commend you for that. Although I happen to be a practitioner I am absolutely also a patient and very active with other patients in trying to help them get the help they need and empowering them to do so. I am a rare neuroendocrine tumor patient & im sure there must be some type of genetic issue as I’ve had many other tumors too (getting genetic testing in May). They type of neuroendocrine tumors I’ve had should, if one only relies on medical literature, make me severely distorted as well as obese. Having done quite a bit of modeling I apparently didn’t fit the textbook mold so much so that one doctor in a horrible and demeaning manner forced me to retest while being constantly in the presence of staff. I had already been doing psychotherapy and had taken many pre-med courses, so my interest in the psychodynamics of how patients and physicians form decisions became of great interest to me.

I have no doubt that patients who are unwell and seeking medical assistance just want answers and a means to get back to their lives. The people that have say a munchausen process are so statistically low so when a patient seeking answers goes to a physician and notices something off in records, instead of being defensive or brazen in their absolute certainty, they need to pause and consider that the patient likely spent considerable amount of time researching and be humble because it’s impossible to recall every single thing ever learned in med school or through patient experience.

And yet… The absolutely not, the words that surely stung you, probably altered the manner in which you viewed the doctor.

I’m glad you are on top of your health. If you ever need a second set of eyes to brainstorm with track me down. You will always find some people in every profession who don’t and maybe can’t meet you where you need to be. That’s just life. Just try not to let it get you down or make you doubt your own skills or instinct. I’m blessed in that I’ve been able to help people that weren’t able or frankly too exhausted to sort through things themselves. I’m blessed because I’ve been able to be called on by several doctors who equally don’t have the time to sort through a challenging case. And I’m really blessed because what I’ve done to basically save my life and get myself proper care has developed into an actual career. I have a book hopefully coming out in late 2017. It’s called “The Cult of Kin” and documents in a novel form the true story of a family destroyed by illness and a cancer researcher who tried to hide data about a patient in order to obtain fame & financial gain. I’ll be including a lot of my methods for medical navigation and the psychopathology of the process in families & within the medical system. Part education, part medical drama.

Be strong!

Cheryl Prevor Psy.D

I agree, wanting to be involved and make educated decisions is quite different than control or even paranoia. It’s a patient’s body, their health, frankly I think only a fool wouldn’t want to know as much as they can. That’s intellect and it serves no one for a patient to be ignorant. Knowledge may even spark a reminder to tell a physician about a symptom they forgot. It can be quite helpful to have educated patients.

Cheryl Prevor Psy.D

When it comes down to it almost all the practitioners I know would be happy to talk with a patient and go over records and insure all on same page. The great tragedy of medicine right now is that the system doesn’t allow that luxury. There are a lot of pressures on physicians based on hospitals or finances to see an extreme amount of patients per day. I’m sad for that. I’ve seen the stress. If we can all agree that this is happening maybe in the end practitioners can look upon patients getting their reports as an asset in the sense that it puts another set of eyes onto the data without further placing time on the practitioner.

vicnicholls

That’s the way it works with most of my group. I earned that trust because I only pick solid medical reference materials they would.

Cheryl Prevor Psy.D

Love this! Not sure why practitioners should be so sensitive to patients wanting to know as much as they can. Of course we need to earn trust, that’s part of life for every single situation. Medicine isn’t any different, I’m glad as it seems you have some method established in your group as to how to deal with and help patients achieve what they need to trust.

Cheryl Prevor Psy.D

Im not sure why your lab is sending you anything without a request from you. No doubt your doctor or staff should go over any results first and then, and only then, if you wish to see your results you should ask. I’d mention this to your practitioner. It’s actually a violation of policy to send you anything without request or review.

Cheryl Prevor Psy.D

Is it really that hard to read a blood test? In addition to the format showing ranges the markers of high and low are pretty clear. It’s kind of silly to suggest one needs to go to med school to understand blood test results as it’s just book smarts and hopefully most can do such things, when you get perhaps to the nuances of utilizing the labs to diagnose or assessing how medication might impact that person we are talking about a higher )but still frankly achievable) level of functioning.

It’s not hard to read a blood test result. So try if you can to accept that patients usually can do this and most important that they likely have much more time than you might to read their blood tests and compare them test by test to prior labs and that maybe that’s a really good thing because it is the patient that might notice that their labs are trending in a pattern and assist you in going into a direction of a plan.

vicnicholls

My records have been read by tons of admin people. I’ve asked why. Never got an answer. Not suing any one. I do ask questions though, I tell you my concerns, I jump on orders because I have several things to work around making it hard to do so.

vicnicholls

You missed IT people. Dr. Reidbord would say we’re argumentative because we over analyze, run things in spreadsheets, computers …

I’m thinking of doing mine into business intelligence powerpoints … 🙂

vicnicholls

That is awesome! Congrats!

The problem with asking questions is many don’t like it. Someone needs to ask the doctors of SIDM why that is so. If you are on a list that discovers and knows about errors, you should be able to handle that. If docs can’t that makes them suspect.

vicnicholls

well read the medical stuff. Not Dr. Oz, but real medical stuff. It is not that hard to pick up, contrary to what many say. I understand docs don’t have tons of time: so why not allow people to help you help them?

Cheryl Prevor Psy.D

Doc Steven…

Just a reminder, I’m just one random woman on the internet who happens to think how you personally perceive yourself, others and the world, is very likely having a negative impact on how you practice medicine. My opinion bothered you or you wouldn’t have kept writing back being argumentative & comparing the trust patients have in a bridge be extended to you. You sure couldn’t control the impulse to engage in the rather callous act of using a different discussion I had about a disease & twisting it back to be about “modeling.”

I’m just a random person & you struggled with my having a different opinion of you than you have of yourself (ironically most talk was general, but you made it specific about you). Please try to learn from this because now you’ve put all this on the Internet and your patients many end up doing a search on you, especially if you behave intolerant of how they want to participate in their medical care. They will end up finding posts that demonstrate that you think they are somehow less than you. Finally, how you react to this utterly benign discussion is demonstrating how you are likely interacting with your patients as we’ve all agreed few are walking in with full comfort or trust. In fact, they probably don’t feel so well so they won’t likely be up to appeasing.

Your opinion (or, ahem, “enlightenment”) bothered me because you wrap yourself in the mantle of psychology, a field I happen to respect, to pursue a personal vendetta against physicians. You maintain a stance of judgmental superiority over those in a field you don’t practice yourself, and see no hypocrisy in touting your own expertise while devaluing the expertise of others. You have the gall to opine about how I practice medicine when you don’t know me. Pure bias and prejudice, the very thing you see in MDs. Project much?

I’ve been active online, using my real name, since the late 1980s. I stand behind everything I write, and welcome past, current, or future patients to read it. Indeed, I write with that in mind. I have a view of patient empowerment and autonomy that goes well beyond political grandstanding, zero-sum games, and putdowns. My friends call me Steven, Dr. Prevor, so I’d appreciate if you’d temper your condescension enough to refrain from doing so. And that really is all from me.

Cheryl Prevor Psy.D

Whoa…
It’s now getting a little weird and frankly a lot pathetic that you can’t let this go.